GW1-2022-04709_Well Construction - GW1_20220511

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
i
Raymond Brown III 14.WATER ZONES
FROM TO I DESCRIPTION
Well Contractor Name
ft. p ft. �
2313 (CJ✓ ft. fr.
o I
NC Well Contractor Certification Number 15.OUTER CASING for Hi
-c d wells OR LINER H ii `licable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESSI MATERIAL
0 ft 74 ft' 61/4 1° sd,21 Galvanized
Company Name
a 16.INNER CASING OR TUBING eothermal closed-loop)'
2.Well Construction Permit#:4346WELN21 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) ft. ft. In.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROME TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
1 Industrial/Commercial IDResidential Water Supply(shared) 18.GROUT
I Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Hole Plug Pour
3 Monitoring C3Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge E30roundwater Remediation
19.SAND/GRAVEL'PACK'if applicable)
'
Aquifer Storage and Recovery E3Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology E3Sulbsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.)
0 ft. 20 ft. Red Clay
4.Date Well(s)Completed: 3/7/22 Well ID# 20 ft. 69 ft. Sand Rock
5a.Well Location: 69 f• 185 ft- Blue Granite
Gordon &Sandra Wilbur ft. fL
mrinfrnn
Facility/Owner Name Facility ID#(if applicable) ft. ft
LJ
3705 Swep Sax Rd ft. fa
Physical Address,City,and Zip ft. ft.
Alatnance 3"21i REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latflong is sufficient) 22.Certification:
N W 3/7/22
6.Is(are)the well(S)OPermanent or OTemporary Signature eCertified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Oyes or MNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also'attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 185 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use'•+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 15 Method of test: sight 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chlorine Amount: 6Oz completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016